Kent Bottles: Maybe Being Wrong is Better and More Human than Being Right

July 6, 2010 at 8:14 am 12 comments

St. Augustine: “Fallor ergo sum”

When I was in charge of the medical residency programs in Grand Rapids, Michigan, David Leach introduced me to the expanded Dreyfus Model of how physicians can progress from beginners to masters.  I was always struck by how master physicians freely admitted their mistakes and used them as a teaching tool.  As a young surgical and cytopathologist, my sanity was saved more than once by University of California San Francisco’s Dr. Theodore R. Miller, a true master of cytology, being willing to share with me some of his mistakes.  I do not honestly think I could have survived in diagnostic pathology without his guidance and wisdom.  Years later, I still remember Dr. Miller showing me a breast fine needle aspiration biopsy slide of fat necrosis that mimicked ductal carcinoma and a case of wrongly diagnosed pancreatic cancer that turned out to be inflammatory atypia.

Mistakes and errors are on my mind because I just finished reading some extraordinary works.

Kathryn Schulz’s Being Wrong: Adventures in the Margin of Error (New York: Ecco, 2010) has convinced me that we should replace our usual pessimistic model of error with an optimistic model of error.  All physicians make mistakes and are familiar with the former model and the accompanying feelings of worthlessness, shame, and depression.  Recalling cases where I got the diagnosis wrong still make me want to throw up years later.  Schulz is right when she writes, “being wrong runs a narrow, unhappy gamut from nauseating to worse than death.”

Some of my own errors formed the basis for my chapter “Pitfalls in Cytology of the Breast” in Errors and Pitfalls in Diagnostic Cytology (Baltimore: Williams & Wilkins, 1997), and I still remember being uncomfortable giving the lecture to the International Academy of Pathology in Washington, DC in 1997.  Admitting to mistakes might mean I was a bad pathologist; being a bad pathologist felt a lot like being a bad person. That day at the Hilton Hotel on the podium I did not feel like a master pathologist.

Schulz contrasts this pessimistic reaction to error with an optimistic reaction where one can be baffled, fascinated, amused, excited and delighted by owning up to a mistake.  She quotes both William James and Henri Bergson to great affect.

“Our errors are surely not such awfully solemn things.  In a world where we are so certain to incur them in spite of all our caution, a certain lightness of heart seems healthier than this excessive nervousness on their behalf.”                                              James

“Look upon life as a disinterested spectator.  Many a drama will turn into comedy.”                                                                                                                                                                            Bergson

Henry Petroski’s Success Through Failure: The Paradox of Design (Princeton: Princeton University Press, 2006) argues for the optimistic view of mistakes in examples such as bridge design, tall building architecture, bicycle lock design, and NASA’s Challenger tragedy.  Over and over again, Petroski shows how success teaches us very little and failure teaches us a lot. The creed at IDEO, the famous design company, is “’Fail early, fail often.’”  Professor Jack Matson believes so strongly in the role of failure in design that he expects students in his Innovative Engineering Design course at Penn State University to fail in order to pass.  “Innovation requires that you go beyond the known into the unknown, where there might be trap doors and blind alleys.  You’ve got to map the unknown.  You map it by making mistakes.”

What really got me thinking about error in a new way was Schulz’s treatment of illusions.  I was already familiar with the two faces/vase and old woman/young woman visual illusions, but I was blown away by Scottish explorer John Ross discovering the illusory Croker Mountains in Lancaster Sound and American Robert Peary who saw a mirage of an entire continent in northern Canada.  Although Ross’ illusion ruined his career, our usual response to illusions is amusement and wonder.  Illusions really do upend our conventional reaction to being wrong.

This amazing book by Schulz made me think about life in a new way.  Her thoughts on St. Augustine, Dadaism, zealotry, groupthink, Ben Franklin, and the Talmud convince me that to be human is to make mistakes.  Just one example: according to the Talmud, “if there is an unanimous guilty verdict in a death penalty case, the defendant must be allowed to go free – a provision intended to ensure that, in matters so serious that someone’s life is on the line, at least one person has prevented groupthink by providing a dissenting opinion.”

In The Invisible Gorilla: And Other Ways Our Intuitions Deceive Us (New York: Crown, 2010) Christopher Chabris and Daniel Simons expanded my appreciation for humans making mistakes by explaining the brain’s illusion of knowledge.  Examples include the world’s leading geneticists predicting that humans have between 25,747 to 153,478 genes when the right answer is 20,500. Leon Rozenblit and Frank Keil did dozens of experiments which all showed that we are “blissfully unaware of the shortcomings in our own knowledge.” For example, The Big Dig in Boston cost 250% more than originally planned because the civil engineers thought they knew more than they really did about putting streets underground.  The authors also remark that our illusions all tend to cast an overly favorable light on human mental capacities. “There are no illusions of blindness, amnesia, idiocy, and cluelessness.”  Later in this blog, we will see they may be wrong here. It is also sobering to note that people with depression are said to have a more accurate view of their relationship to reality than others who are not depressed.

I zeroed in on Jonah Lehrer’s treatment of mistakes in How We Decide (Boston:  Mariner Books, 2010), and I think Schulz would be happy with his effort.  Bill Robertie, a world-class expert at chess, poker, and backgammon, claims that the way to improve is to focus on mistakes.  The famed physicist Niels Bohr defines an expert as “a person who has made all the mistakes that can be made in a very narrow field.”  I was impressed by Carol Dweck’s studies at Stanford that showed that praising students for their intelligence resulted in worse performances than praising students for their effort.  However, I was most impressed by the story of Michael Riley of the Royal Navy and how he used his intuition to correctly differentiate a silkworm missile from a friendly airplane by listening to his intuition and his dopamine receptor.

Since mistakes are such a central part of human life, one would think we would get really good at apologizing.  Think again.  Lisa Belkin nicely summarizes how difficult it is for us to say sorry sincerely (http://nyti.ms/dnZ230).  Although apologies are “the most profound of human interactions” that can heal and resolve guilt and anger, some now see many non-apology apologies that do not satisfy either the sinner or the victim.  Think recent apologies by Tiger Woods or BP’s Tony Hayward.  Or maybe an even better example of non-apology apologies is GOP Congressman Joe Barton apologizing to BP and then apologizing for apologizing to BP.

According to Belkin, some states have passed laws making a doctor’s apology inadmissible as evidence in a lawsuit, in the belief that patients find solace when a doctor admits a mistake, and that doctors are more likely to do so if they are taking part in a conversation and not a confession. “These laws might well free doctors to speak more honestly with patients and families and allow for a chance to truly repair their relationship. Or they might have the opposite effect entirely. With less at stake for the doctors, could apologies become pro forma and, as a result, less powerful?”

My friends, family, and co-workers were getting tired of me raving about the above four books, when I stumbled upon something even more mind boggling: Errol Morris’ The Anosognosic’s Dilemma:  Something’s Wrong but You’ll Never Know What It Is (Parts 1-5) (http://ow.ly/26IeJ).

This article ricochets from Donald Rumsfeld to McArthur Wheeler (a hapless bank robber who thought lemon juice would make him invisible) to the famed neurologist Joseph Babinski to President Woodrow Wilson to Marcel Proust to surrealism.  The starting point is the Dunning-Kruger Effect which was described in a landmark article titled “Unskilled and Unaware of It: How Difficulties of Recognizing One’s Own Incompetence Lead to Inflated Self-assessment.”

Anosognosia (from the title of the Morris article) is a condition in which a person who suffers from a disability seems unaware of or denies the existence of his or her disability; it was first described by Babinski in patients who were paralyzed but refused to acknowledge their problem.

Morris thinks deeply and creatively about “known unknowns,” “unknown unknowns,” and “unknowable unknowns.”  In interviewing David Dunning, he discusses how the mediocre doctor is not aware of diagnostic possibilities and treatments that he never considers.  More disturbing is a study of medical students which shows that those at the bottom of the class cannot learn by being shown what the smart students are doing to progress along the Dreyfus model of competence.  They are like McArthur Wheeler who was too stupid to know that he was too stupid to successfully rob banks.

Morris’ epilogue states:

I have to admit my fondness for the Dunning-Kruger Effect.  But is it a metaphor for existence? For the human condition?  That we’re all dumb and delusional?  So dumb and delusional that we can never grasp that fact?  It’s so profoundly depressing and disturbing.  Even sad.  Dunning gives us no hope.  The McArthur Wheelers of this world will never understand their limitations.  But aren’t we all McArthur Wheelers?  (http://ow.ly/26IPb)

I think we are all McArthur Wheelers, but I am comforted by V. S. Ramachandra’s observation that “It may well be our brains are wired up to be slightly more optimistic than they should be.” (http://ow.ly/26N9k)  For any physician to be a master diagnostician he or she must learn from mistakes and also be acutely aware of what they know they don’t know.  They must also admit that some things about people and their ailments are just unknowable.  Making mistakes does not make you a bad doctor or a bad person.  Making mistakes makes you a human being.  Get used to it.  And learn how to apologize sincerely.  You might want to read On Apology by Aaron Lazare, MD (Oxford: Oxford University Press, 2005).  I just did, and I have a lot of work to do.

Entry filed under: General Info. Tags: .

Gary Oftedahl: Empowerment/Engagement…Easy Does It Kent Bottles: Will CER Really Make a Difference if the Public Doesn’t Want It?

12 Comments

  • 1. Alan Burgener  |  July 6, 2010 at 9:42 am

    This an entertaining and provocative musing, which I enjoyed. It seems to me that all human intelligence, at the individual level, is comprised of a) the things that we truly and legitimately “know”, b) the things that we don’t know and understand that we don’t know, and c) the things that we don’t know that we don’t know. The latter category is every person’s “blind spot” and the goal of lifelong learning should be — to the extent possible — to move content from (c) to (b) to (a). No one ever completes this job, but making continuous progress is a noble aspiration — and moving content from (c) to (b) is arguably the most important thing we can do in becoming better human beings. It’s much less important in the long run to know many things than to recognize the things that we don’t know.

    I also liked the section in which you make the case that the depressed are more in tune with reality than others. It reminded me of one of my favorite statements: A pessimist is merely an optimist with experience.

  • [...] This post was mentioned on Twitter by Phil Baumann, KentBottles and others. KentBottles said: @wrongologist http://ow.ly/27yIP When being wrong is better than being right and how do you know what you don't know [...]

  • [...] more here:  Kent Bottles: Maybe Being Wrong is Better and More Human than … By admin | category: KENT | tags: david, david-leach, human, KENT, medical, michigan, [...]

  • 4. Anne Marie Cunningham  |  July 6, 2010 at 5:11 pm

    Intriguing as always! I’ve pre-ordered the Schulz book- it is not out in the UK until September.
    We are poor at recognising our competencies and lack of them. Regehr and Eva have suggested that this poses problems for the self-regulated learning in medicine:

    http://www.ncbi.nlm.nih.gov/pubmed/16735869

    I take your point about learning to live with mistakes. I feel that the appraisal system in the primary care in Wales (if not all the UK) is good at encouraging this approach- but can we teach students how to reflect and recognise the weaknesses of their practice?

    I think that medicine is too serious for:
    “Look upon life as a disinterested spectator. Many a drama will turn into comedy.”

    It is because I care about my practice, and don’t treat it as a disinterested spectator, that I try my best to learn from my experiences- what went right and what went wrong. I am still a biased observer however!

  • 5. Mental Disorders 101  |  July 6, 2010 at 5:39 pm

    Kent Bottles: Maybe Being Wrong is Better and More Human than Being Right…

    I found your entry interesting do I’ve added a Trackback to it on my weblog :)…

  • 6. Bill Yates  |  July 6, 2010 at 11:04 pm

    Great post Kent! I have been thinking quite a bit about anosognosia. I think the issue that fascinates me is the role of aging and lack of insight into reduced capabilities

    Grandpa says he’s still a good driver when everyone knows he should not be driving. Grandpa has lost his ability to judge his true driving skill.

    Joe Paterno says he still can coach. Penn State builds a support system around Joe to make sure the football team is competitive.

    We all know people who stayed on too long. When you stay on too long it will often ends badly when you don’t recognize your decline in performance.

    I stepped down as a chairman of a medical school department at age 56 confident I was effective on my last day. I knew that it’s better to leave too soon than to risk losing the ability to recognize when you’ve stayed on too long.

    It’s great to be confident about your beliefs and abilities. But it’s even better to recognize your beliefs could be wrong and keep that possibility in mind when making choices.

  • 7. Christine Kraft  |  July 9, 2010 at 5:50 am

    Another angle on this issue is through the lens of nature, landscape in particular.

    Trees lose limbs but still they are trees. Our “sadness” is triggered by the thinking we bring to the tree’s loss. We give meaning to the loss and that’s what makes it painful. With human loss the pain is that much greater. So The question becomes how to manage the pain. Is there a way?

    Check out the work of Stephen C. Hayes, Ph.D. in the field of Acceptance and Commitment Therapy, a scientifcally based psychotherapeutic modality within behavioral and cognitive therapy. Lots to read from him, but here’s a 2006 Salon piece: http://www.salon.com/life/feature/2006/02/25/happiness that may be interesting to you.

    • 8. Joe McCarthy  |  July 12, 2010 at 4:28 pm

      Thanks for sharing the link to Hayes’ interview on Salon, Getting Over Happiness.

      I want to share the article’s subtitle, in case it may encourage other readers of your comment to click on the link:

      “Psychologist Steven Hayes says the American obsession with feeling good is preventing us from living good — and that living life to the fullest means a lot of pain. “

  • [...] The next to submit is Kent Bottles MD, president of the Institute for Clinical Systems Improvement (ICSI). He’s deep, as his blog posts suggest, and patient-oriented; he’s the farthest thing from paternalism you could imagine. (Most recent posts: Will Comparative Effectiveness Research Really Make a Difference if the Public Doesn’t Want It? and Maybe Being Wrong is Better and More Human than Being Right.) [...]

  • 10. Cat Chen  |  July 9, 2010 at 10:39 am

    Phenomenal post Kent. Insightful and entertaining as always!

  • 11. kent bottles  |  July 9, 2010 at 5:00 pm

    Reading an intriguing book called The Undiscovered Dewey: Religion, Morality, and the Ethos of Democracy by Melvin L. Rogers and came across two quotes that seem to address the topic of this blog:

    “Where hope is unchecked by any experience, it is likely our optimism is extravagant” Charles S. Peirce

    “When the future arrives with its inevitable disappointments as well as fulfillments, and with new sources of trouble, failure loses something of its fatality, and suffering yields fruit of instruction not bitterness. Humility is more demanded at our moments of triumph than at those of failure. For humility is not caddish self depreciation. It is the sense of our slight inability even with our best intelligence and effort to command events; a sense of our dependence upon forces that go their way without our wish and plan.” John Dewey

  • 12. Joe McCarthy  |  July 12, 2010 at 4:15 pm

    Great synthesis of several interesting and related threads!

    I haven’t read Kathryn Schultz’ book yet, and after reading this post, I have a few more books on my #toread list.

    I heard an interview with Schultz on our local NPR affiliate, KUOW, in which she talked about inductive (vs. deductive) reasoning as one of the most powerful tools humans use to advance knowledge … and the concomitant need to be able – and willing (!) – to identify and correct the inevitable errors that result in reasoning from specifics to more general “truths”.

    I think anyone who has studied science sees the wisdom in the observation by George Box: all models are wrong, some are useful.

    Your presentation of the Dunning-Kruger Effect reminds me of fundamentalism – whether it be religious, political or economic – and the inattentional blindness that is often intentionally cultivated among disciples.

    It takes sustained effort to be willing to question things, and make corrections to one’s life and work, and I can understand the appeal to simply marking certain areas “off limits” to doubt … but if we are to continue making progress, I believe we need to more open to the wisdom of wrongology.


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